30 Apr 2021

Health Ministry criticised over Southern DHB's membership of bowel screening programme

10:24 am on 30 April 2021

A surgeon and a cancer researcher have accused the Ministry of Health of allowing the Southern District Health Board (SDHB) to join the National Bowel Screening Programme too early saying the decision has cost lives and delayed treatment for cancer sufferers.

Hospital hallway, doctor, nurse, file pic, generic

Photo: 123RF

Dr Philip Bagshaw and Professor Brian Cox have reviewed more than 3500 pages of documents received under the Official Information Act.

They along with Paula Goodman, have published their findings in the New Zealand Medical Journal today.

"The introduction of new health policy and services must be accompanied by well-defined lines of responsibility and accountability, particularly in environments of constrained resource. Where new policy or service provision creates inequities in access, as this innovation has, clear leadership and accountability for remediation is essential," they wrote.

"The potential for harm to symptomatic patients resulting from the additional demand on already limited resources occasioned by the introduction of the National Bowel Screening Programme warrants further research.

"Good bowel screening programmes and timely colonoscopy for symptomatic patients are equally important in the battle against CRC [colorectal cancer]. This is particularly so in a country such as New Zealand where CRC is so common. Indeed, screening should have started here many years earlier, should have a lower positive test threshold, and should provide coverage starting at a younger age, particularly for Māori.

"Both screening and symptomatic colonoscopy services must be adequately resourced (probably the main underlying problem) and run separately so they are never allowed to compete for resources-as they did in the SDHB."

Neither the Southern District Health Board nor the ministry were available for interviews, though the SDHB did refute the assessment in a statement which labelled the programme a success while acknowledging further colonoscopy capacity was needed.

Bagshaw and Cox told RNZ the Southern District Health Board did not have enough existing capacity to perform colonoscopies on all of those showing symptoms of colorectal cancer when it joined the National Bowel Screening Programme in 2018.

That meant patients on the screening programme were prioritised over those who were already suffering cancer symptoms, Cox said.

The pair labelled such decisions as unethical and Cox said for some people it resulted in a deadly delay in getting treatment.

"For some patients their [diagnosis] was significantly delayed to the point that treatment, when it was instituted, was much less likely to be successful and for some of them, unfortunately, may well have resulted in untimely death from bowel cancer," he said.

However, the problem was entirely predictable.

"The Southern District Health Board had a high proportion - relative to other areas - of people who presented to emergency departments with bowel cancer even before the screening programme started. So there were difficulties in people with symptoms getting access to colonoscopy services before the screening programme even began," Cox said.

Documents obtained under the Official Information Act showed Ministry of Health staff in the bowel screening programme team had misgivings about whether the SDHB was ready to join the programme.

"In a memo requesting permission from NBSP [National Bowel Screening Programme] Governance and Leadership Groups for SDHB to go live with screening, NBSP personnel note having received a letter from the SDHB CEO giving assurance that there will be sufficient colonoscopy capacity," the article in the New Zealand Medical Journal said.

"The letter obtained under OIA offers no such assurance of sufficient colonoscopy capacity. Despite this, permission was granted on 17 April 2018 - in our opinion inappropriately - and screening commenced in the SDHB region on 24 April 2018.

"The MoH was asked to confirm if the CEO letter of assurance provided under OIA was the only written assurance as to capacity availability obtained from the SDHB in the process to commence bowel screening in that region.

"A letter of reply from the MoH (Population Health and Prevention) in October 2020 confirmed that: (i) there is no additional written correspondence the MoH received from SDHB beyond what was sent to us in August 2020; (ii) "the decisions relating to SDHB were taken by an earlier leadership team so [they were] unable to provide further context"; and (iii) "the delivery by SDHB of a consistently high-performing bowel screening programme, exceeding national targets would suggest the confirmation of readiness was sound."

"On the evidence, we conclude the process to assess SDHB capacity to assume NBSP did not ask critical questions. Further, the SDHB was not required by the assessment process to disclose relevant issues, and apparently did not choose to disclose voluntarily," the trio said in the article.

Cox said he believed political gain had been put ahead of clinical safety.

"I think there was certainly a lot of political push, in a sense that the Ministry of Health wanted to be able to say that the National Bowel Screening Programme was expanding to include Southern District Health Board, which has the highest rates of bowel cancer in the country. So political expediency, I think, has overseen clinical safety," Cox told RNZ.

Philip Bagshaw, who co-authored a highly critical report of Southern District Health Board's colonoscopy service, said SDHB needed more resource so it could offer the much needed screening service without compromising timely diagnosis for patients with symptoms.

"The Southern District Health Board did not fulfil all the criteria ... in the assessment process to be admitted to the screening programme and the criteria used by the Ministry of Health to determine whether it was suitable or not are completely flawed and would not have picked up the deficiencies that were there," he said.

His attempts to get answers as to why Southern was allowed to join the programme had been frustrating.

"When we found deficiencies a lot of people who were responsible ran for cover. But there was one person really who was a hero in all of this and that was Dave Cull, who stepped up and said people had suffered unduly and apologised to them," Bagshaw said.

Dave Cull stepped down as the SDHB's chair in October following a diagnosis of pancreatic cancer. He died earlier this week.

Cox and Bagshaw agreed the decision to allow the board into the screening programme showed systemic failings at a national level which they fear might be happening elsewhere as the National Bowel Screening Programme is rolled out around the country.

They want more rigourous assessments of DHBs.

In a statement, Southern District Health Board's chief executive Chris Fleming said the bowel screening programme had been an "overwhelming success at Southern DHB, and any concerns raised need to be understood in the context of the overall benefits to our community".

"We have higher than anticipated participation in the programme, and the highest participation rates in New Zealand for Māori," the statement said.

"The programme has so far detected over 235 cancers, that would not otherwise have been detected at such an early stage, and polyps (pre-cancerous lesions) in over 1800 participants.

"Critically, by diagnosing cancer at a much earlier stage of the disease, the opportunity to achieve a successful outcome from treatment is increased."

Fleming said that was not at the cost of symptomatic patients.

He said the number of symptomatic patients increased following the programme's introduction, likely due to more awareness of the disease and its symptoms.

The waiting time for these patients is still within the national indicator timeframe, he said.

"We do, however, acknowledge that we need to continue to grow our capacity to conduct colonoscopy services in the Southern district and there are ongoing activities to improve our services."

The Ministry of Health also characterised the programme as a success.

"Since its launch in 2018, Southern DHB's National Bowel Screening Programme has been extremely successful with the DHB reporting high overall participation rates and seeing sustained benefits for screening and colonoscopy uptake," a statement said.

"The biggest benefit of screening is that of the cancers diagnosed by screening in the Southern DHB region 32.7 percent were at stage 1 which has a 90 percent 5 year survival rate, with only 3 percent identified at stage 4 (the most advanced stage); whilst in the non-screened population approximately 11 percent of the cancers were diagnosed at stage 1 and around 24 percent at stage 4."

The statement said that the ministry has always aimed "to ensure that the DHB has everything in place to deliver a quality screening programme and has made the required adjustments so that any impact on symptomatic services is minimised".

"Lead Clinicians from DHB services who are impacted by bowel screening are involved both before and at the readiness assessment before the programme goes live to ensure the Programme works successfully alongside other aspects of the service," it said.

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